Emergency Emergency – the perilous state of Emergency care provision in Northern Ireland

Much has been made in the press in recent days about the crisis in local hospitals. Planned surgery has been cancelled to cope with the deluge in Accident and Emergency units. The system is certainly under strain and medical staff are under significant pressure. I thought it would be interesting to crunch the numbers to see how the difficulties being faced here compare to those in Britain.

There is a nationwide target in Emergency units to treat, discharge, or admit 95% of A&E cases within four hours (the target is 98% in Scotland). Northern Ireland has, by far, the worst performance of the four UK constituent regions/countries. Since 2008, when Northern Ireland statistics on A&E performance start, a significant gap has opened up between performance in Northern Ireland and that in Great Britain in “Type 1”, or major 24 hour Emergency units.

Nation Comparison

What started as a gap of 8% has grown to a gap of more than 20%, and with the crisis in recent weeks, the trend is liable to worsen (in the graph above, Q1 starts in April, so the data runs until September 2014).

In fact, of all the 51 NHS Regional Units (Trusts or Area Teams) in the UK in September 2014, all three of the worst performing were in Northern Ireland; Belfast, Northern, and the South Eastern HSC Trusts. The Royal Victoria hospital dealt with 64.5% cases within four hours, in the Mater the figure was 67.9%. These were, by some distance, the worst performing Emergency units in all of the UK.

So, what is the reason for this poor performance? Is it due to an unprecedented spike in demand? In fact, there hasn’t been a spike in demand. Numbers presenting themselves to Emergency units have remained relatively stable, with predictable seasonal fluctuations, over the last seven years.

NI New Cases

So, if cases have remained stable and followed a predictable seasonal variation, what could be to blame for the poor performance of Northern Ireland hospitals compared to those in Britain? Is there a significant difference in health spending per head? Well, there is indeed.

Health Spending per head

This 2012 report of the National Audit Office shows that health spending per capita is higher in Northern Ireland than it is in England, Scotland or Wales.

So, we are left with something of a mystery. Since the reestablishment of the Northern Ireland Assembly, the performance of Accident and Emergency units has markedly deteriorated compared to those in Great Britain, whilst per capita spending has remained the highest in the UK. Are we entitled to ask why we are receiving a second rate service? It certainly isn’t due to any failing in the professionalism and hard work of hospital medical staff who, whilst I don’t have hard data to hand to back this up, in my experience perform their jobs with heroic skill and care in very difficult circumstances. But the fact remains, in terms of waiting times, Northern Ireland has the worst Accident and Emergency provision in the UK. Why?

  • John Gardiner

    Is the NI spend on health alone or on Health and Social Services?

  • hugh mccloy

    Salmon Of Data you will find more A&E stats here, I complied them for the TYC response, also bed levels, population stats http://savethemid.weebly.com/tyc-response-2013.html and more including deaths in A&E here http://savethemid.weebly.com/news/over-1600-deaths-in-northern-ireland-aes-since-20091 .

    The why is a simple capacity issue, wards fill up, A&E’s fill up and cannot discharge to wards and everything stops, see other post on Slugger here http://sluggerotoole.com/2015/01/07/crisis-what-crisis/

  • Zig70

    Graphs are nice. What about a process flow with hidden factories for more in depth data? I’m sure someone in NI NHS does that kind of analysis. Maybe the question should be asked.

  • Jeffrey Peel

    Excellent piece that shows that spending levels are not correlated with quality care

  • Old Mortality

    Salmon
    It certainly isn’t due to any failing in the professionalism and hard work of hospital medical staff who, whilst I don’t have hard data to hand to back this up, in my experience perform their jobs with heroic skill and care in very difficult circumstances.’

    If you don’t have hard data, then don’t make the witless assumption that ‘aren’t all our doctors and nurses just wonderful’. That’s not been my experience although it is, thankfully, very limited

  • Zeno

    I agree with that.

    “perform their jobs with heroic skill and care in very difficult circumstances.'”

    That phrase is repeated every time the hospitals are mentioned. It has been repeated so many time that is has become an acknowledged “fact”

    The truth is some of them are indeed excellent and some are worse than useless. I put it down to nursing becoming a career rather than the vocation it once was. It attracts the wrong people. Doctors are the same. I think that is due to the financial rewards.

  • Kevin Breslin

    So, we are left with something of a mystery.

    Erm It’s not a mystery, why England spends less per head.

    Health is a lot more difficult to administer in a Northern Ireland than England, Specialists are much more difficult to find in Northern Ireland than in England. Comparing with England as a whole is futile, most of the population is urbanised, we also put more pressure on a health services.

    Also if Northern Ireland turned away anyone with an income of £6,000 a year, drunks, alcoholics, old people, those already disabled, the mentally ill … they could beat the English statistics in a heartbeat. How can we know from a bar chart that English hospitals are as honest as the ones in Northern Ireland on their statutory duty from a mere bar chart? That’s assumed they are not, but it’s not proven.

    There’s a few fools out there who think Northern Ireland is exactly like England, and that a bar chart or two is enough to make a sound economic analysis from.

  • Zeno

    If Northern Ireland turned away anyone with an income of £6,000 a year

    I don’t understand that sentence? You are correct that there are economies of scale not available in NI and that is one of the reasons all of our services cost more. The Bar Chart confirms that as population increases the cost per head falls. But without looking at it in further we don’t know if that is the whole story.
    It’s odd that the hospitals seemed to cope when we had major incidents almost every day like bombs and murders, yet a bout of flu knocks them out now.

  • Kevin Breslin

    Why do assume that Northern Ireland will be as Pareto-efficient as England, simply by spending at the same level as England?

    Isn’t not the case that the main root of the inefficiency is not waste and fat but that the premise that speaking English, using some form of pound sterling and using a St George flag for your nation means that everything else between England and Northern Ireland can be exactly the same is utterly false.

    It isn’t and it will never be. Just get used to it and stop deluding yourself.

  • hugh mccloy

    One major difference is that the commissioning of social care is done by the local councils, where as here it is done through the trusts

  • Paul Kerr

    I think some of the reasons for the problems are quite easy to see if you know where to look , the article above represents a traditional obfuscation used by many to disguise some major problems in the NI emergency care system.

    Attendances have gone up quite dramatically in all large units (less of these now) and the number of hospital beds dramatically down while there are rising ambulance arrivals and higher GP referral rates for specialty services.

    The changes make emergency care in hospitals a highly cost effective system , but very lean indeed with no ability to respond to surges in activity.

    As contracts have changed both primary and secondary the reliance on Emergency Medicine as the only access point for many services and investigations has grown. As activity in primary care has also increased the Emergency service is used more often to access diagnostic tests and specialty opinions that previously were dealt with in the community or outpatients.

    The out of hrs nature and relentless pressure of this work makes it very unnatractive to all but the enthusiasts and hence staffing, both Nursing and Medical is fragile. Contracts failed to reward out of hrs work so training and recruitment have been problematic leaving shortages at the busiest times.

    The cost per capita quoted above has always been higher and reflects the social situation and the demand for healthcare , (also reflected in Emergency department attendance per capita). The Appleby report showed this yrs ago

    The quality of the care patients receive is excellent and it would be difficult to change to a more cost effective system but waiting times mean problems are inevitable. The issue recently is access to beds and it is a shame the discussion is limited to A+E when this is a major system failure outwith our departments

    An Emergency Medicine Summit earlier this yr discussed many of these issues but few changes have been implemented despite much discussion and major change is difficult but urgently needed

    Read the recommendations by the Emergency Doctors for improvements

    http://tinyurl.com/n62o9gm

  • salmonofdata

    So why do our A&E waiting times compare so unfavourably to Wales and Scotland? And urbanisation is not the issue, the situation in Belfast is the worst of all.

  • hugh mccloy

    The use of short stay wards, critical decision units to hide A&E times are not in this. Need to analysis how many attendances needed admitted v bed capacity, and not just capacity on the whole capacity in wards that are created for the illness the patient has. The 30 emergency readmission rate which is already running in the thousands. The media here are very guilty of taking a figure and letting it go without researching everything

  • salmonofdata

    I did say it was only an opinion. But if someone was proposing that the rise in A&E waiting times was due to a fall in the competence and skill of A&E medical staff, I’d want to see the data they were using to back up their assertion.

  • Kevin Breslin

    Wales and Scotland are more like here, but will have better economy of scale. As for Belfast, many of the services in Belfast have to cover most of Northern Ireland. Should we also include what Republic of Ireland patients contribute and take to these services as well?

  • Kevin Breslin

    The point is statistics aren’t the be all and end all. We could get better looking statistics through poor practice.

  • OneNI

    Statistics arent everything but here are some pretty disgraceful basics that we cant get right

    http://www.niconservatives.com/news/ni-executive-failing-cancer-patients

  • puffen

    A break down of back office jobs, e.g. admin and support, and coal face jobs, e.g. nurses, PAMS, domestic staff, and Doctors might shed more light on this, I would say the NHS in Northern Ireland is over managed, in comparison with the rest of the UK. This not only a financial question, there is nothing more likely to demoralise staff, than seeing people in the same organisation bluffing their way and getting away with it.

  • hugh mccloy

    The reason we differ is capacity, ask any GP or A&E doctor. If you look at the stats closely the winter of 2009/10 is when waiting times started to get bad.

    We do however need qualitative information here as well, and in a small way we have it, a very good measure is the 30 emergency readmission rate, which is in the thousands and out of control across all trusts.

    The same people who measured the death rates in Mid Staff have already been in Antrim to try and get some review going, but at the moment all the reports are protected under copyright and not for public view.

    The BHSCT is one of the biggest employers in Europe, unlike NHS in England & Wales those large trusts do not commission social care.

    Also take the comment Belfast is worst of all, I think you will find Antrim & Ulster who are not in the BHSCT have worse stats than the Royal, the Royal only gets the media attention because to the media nothing exists outside of Belfast. Even last year at the height of the crisis in the royal Antrim performance was far worse and it hardly got mentioned.

    To put it into context, we need proper reports to have the context you need

  • chrisjones2

    Why is it a crisis? When demand surges you prioritize. Some people who generally dont really need the services of A&E have to wait.

    The problem is not the waiting time to be seen but the waiting time for those who need admission to get into a ward and that’s where the internal fiefdoms in the NHS start to block the process

  • Old Mortality

    I wasn’t implying that.
    Like Zeno, I dislike the unquestioned assumption that the NHS’s problems cannot possibly ever be blamed on the employees in ‘front-line’ services.
    So long as this attitude prevails, the NHS will continue to be a voracious monster which craven politicians fall over themselves to feed – witness the ludicrous promises on nurses in Scotland and be very afraid.

  • hugh mccloy

    The problem here is hospitals cannot prioritise they can only escalate. Survival and best outcomes come from admission tot he correct ward for your illness, what happens here is in escalation mode extra beds are put into wards just to get the patient away from the A&E cubicle or corridor.

    Considering that our acute system is running escalated over a number of years we have a crisis but it is a ongoing crisis since 2010.

  • hugh mccloy

    That Qualitative data is hard to come by, but NI’s reliance on Locums its a known medical risk to patients, if you search about there are some reports on this in Scotland in the past.

  • Korhomme

    Isn’t it strange, a paradox? In international comparisons the NHS comes out top, or near it, in most of the categories that are measured, but the media and the experience of people on the ground and at the coal face is quite different. Why?

  • Zeno

    Sorry, you lost me.

  • puffen

    Everybody can have a bad day, except you apparently!

  • Catcher in the Rye

    The interesting thing to me is that while various campaigners are screaming “stop the privatization of the NHS” the ground is moving beneath their feet. The NHS will not be privatized, but it will simply become so slow and useless, due to underfunding, that those with the money will pay to have procedures done privately.

  • Dan

    Is the NI NHS still coming down with chancers spending years as full itime Union reps?

  • Kevin Breslin

    I hope you agree with me on this that the National Audit Office, while they do an important job on public finances cannot be the ones relied on to determine the spending priorities or even question the spending abilities of any health service. If the NAO has any information about inappropriate spend and waste of money it should act on that and not on bar chart comparisons between non-identical regions.

  • Kevin Breslin

    We’ll probably end up in a two teir health system like the Republic, that is slow but I will doubt if that health service becomes useless.

  • salmonofdata

    I’m not sure what you are getting at here. I must have missed the part in the report where the NAO was determining spending priorities. Amongst other things, they pointed out that health spending per head in NI is the higher than Scotland, Wales, or any of the English regions except London. Are you suggesting that this information should be secret?

    Also, what do you mean by “non-identical regions”? How can two regions be anything other than “non-identical”?

  • Kevin Breslin

    Well for one, to make a fair geographic comparison taking a region of England or Scotland with a similar population distribution over a similar area would be more effective than a simple per capita measurement.

  • salmonofdata

    On your point regarding Antrim, you are right that they have the worst statistics if you look back to 2008. The average rate for dealing with A&E cases within 4 hours was 70% (the lowest in NI), and they were the worst performing unit in 33 of the 79 months that there is data available for, worse than the RVH (17), BCH (12) or the Mater (11).

    The situation is slightly different if you look at 2013 and 2014 only. Antrim was the worst performing unit in 7 of the 22 months where data is available, but the RVH was the worst in 10 months. Also, the RVH fares slightly worse on average performance against the 4 hour target; Antrim got 70%, whilst the Royal got 68%.

    Whilst Antrim hasn’t improved, the performance of the Belfast EDs has deteriorated to the point where Antrim and the Belfast EDs are as bad as each other.

    On either timescale, the Ulster outperforms both Antrim and the Belfast EDs. Its average since 2008 on the four hour target is 77%, and 72% in 2013 and 2014. It was only the worst performing unit in NI once over this period.

  • hugh mccloy

    I only have access to full stats broken down into type 1,2,3 units from April 2007 to June 2013 for all units on hand here I will have a loo through them. Do you have access to 2014 July to Dec and I can finish the analysis, although I cant see Dec being published yet as they are not usually verified until later in the month

    Looking at 2008, Royal had 89.3%, Ulster 88.5%, Antrim 83.7% in under 4 hours, I will have a closer look at them later.

    Also take into account they system model, type 1,2,3 and when the typing of A&E’s changed

  • jimjam

    The BT published a breakdown of staffing comparisons across the UK about 6 months ago which showed that our excess was mainly in clerical and admin posts. There was very little follow up of this, even from the BBC’s local health corr, who of course gets her “line to take” from Unison.

  • puffen

    This of course is no surprise to me, having worked in the NHS for 38 years, the people who control the levers of power, work far away from the delivery of personal hygiene, and as such care little for patients, to love somebody you have to first wipe their arse, unfortunately the ones in charge have never worked in the wards . and care little. . We are demoralised and no wonder,